April 13, 2014

Democrats Need to Start Blaming the GOP for the Death of Charlene Dill
How liberals should talk about the Medicaid expansion

On Wednesday, the Orlando Weekly published the explosive and infuriating story of Charlene Dill, a struggling, 32-year-old mother of three who collapsed and died on a stranger's floor late last month. According to Weekly reporter Billy Manes, Dill suffered from a treatable heart condition. She also fell into what policy experts call the Medicaid coverage gap—a hole the Supreme Court punctured in the health safety net when seven of its justices rendered the Affordable Care Act's Medicaid expansion entirely voluntary.

Over 20 Republican state governments have ripped that hole wide open by refusing billions of federal dollars, offered on the sole condition that they be used to insure residents who earn less than 138 percent of the federal poverty level. In their states, residents who weren't previously eligible for Medicaid, but currently earn too little to qualify for subsidies to purchase private insurance, are out of luck. Experts estimate that five million people nationwide have fallen into the gap. Nearly a million of those people reside in Florida alone—collateral damage in the GOP's war against Obamacare. Dill was one of those people. She was selling a vacuum cleaner to earn the money she needed to buy her heart medication when she collapsed.

The Weekly article trafficked fairly well, and Dill's actual story went incredibly viral, thanks to the liberal website Think Progress, whose post about the Weekly piece—"This 32-Year-Old Florida Woman Is Dead Because Her State Refused To Expand Medicaid"—has been shared over 62,000 times on Facebook.

Five days later, it has practically vanished from the national Obamacare debate. Hundreds of thousands of people now know Dill's story, but the liberal media isn't really making an issue of it, Democrats outside of Florida have been unusually reticent about it, too, and the Florida legislature remains unwilling to expand its Medicaid program, despite the brief surge of bad publicity.

That cautiousness simultaneously reflects the left's greatest political strength and weakness: its relatively healthy epistemological standards, and its at-times lamentable unwillingness to seize its own political advantage.

The truth about Dill's story is that we'll never know how it would have ended if Florida had expanded its Medicaid program, and Dill had obtained the coverage she sought. It's a counterfactual that's impossible to test precisely because Dill is dead. The Think Progress headline, and the post's lead paragraph, thus rest on an unprovable assertion. It's certainly possible—perhaps likely—that Dill would not have died if she'd been on Medicaid. But we can't say for sure.

And that, I think, helps explain why Dill's name isn't on the lips of every Democratic politician in Washington and non-expansion states around the country. Which is not to say Democrats are always above demagoguing stories like this. The Dem-aligned super PAC Priorities USA endured considerable criticism for producing this famous anti-Romney ad.

I wouldn't be surprised to see Dill's story end up in an ad (in Florida or elsewhere) laying blame for her death at the Republican party's feet. With conservative groups like Americans for Prosperity producing specious, manipulative anti-ACA ads at a blinding clip, it'll be hard for me to get worked up over it if a group like Priorities politicizes Dill's death.

But liberals writ large don't actually need to make any unprovable claims to deploy Dill's story in service of a very strong argument.

Unlike AFP's Obamacare "horror stories" which seem invariably to refute themselves once the omitted facts emerge, Medicaid gap horror stories like Dill's are fairly unambiguous—at least, up until the claim that individual victims died because of Republican policy. People either qualify for Medicaid or they don't. They either qualify for premium tax credits or they don't. Either they're insured when disaster strikes or they're not. It's completely uncontroversial to argue that Dill would have had a more fighting chance at survival if Florida Republicans hadn't refused the expansion against state interest.

Writing in Health Affairs earlier this year, a quartet of public health researchers converted the concept of that "fighting chance" into numbers. In contrast to a recent study out of Oregon, which cast Medicaid's effect on health outcomes into doubt, they estimated that between 7,115 and 17,104 people nation-wide (and between 1,158 and 2,221 people in Florida alone) will die avoidably in the coverage gap over the course of a year. In most if not all of these cases, it will be impossible to declare, definitively, that the victims would still be alive if not for the absence of expanded Medicaid. But both intuition and the bulk of scholarship on the issue tell us that uninsurance carries a mortality risk.

(Using the same logic, you can argue that some insured people die avoidably every year because they allow themselves to be over-treated. But even if the numbers involved were comparable, the two scenarios don't carry equal moral weight. If my hair catches fire and in the process of snuffing it out you accidentally smother me, the lesson is not that you should have let me burn to death instead.)

Back in the real world, uninsured people delay screening for curable cancers, or skip medication, and because uninsurance is so common, some of them invariably die as a result. That's a big part of the moral case for Obamacare's coverage expansion. Charlene Dill's story illustrates the indisputable fact that the people undermining it are putting people's lives at risk. There should be consequences for it.